劃下美麗的句點 ──安寧緩和醫療條例通過

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2000 / 6月

文‧張瓊方


「安寧緩和醫療條例」在五月二十三日三讀通過,從此以後,「自然死」不再違法,估計台灣每年約有十萬名病人在臨終前得以選擇免除急救的痛苦,尊嚴死亡。


安寧緩和醫療俗稱「自然死」,意即依照病人的自主意願,不使用心肺復甦術、人工呼吸器、強心劑、各種插管等維生醫療方式,拖延不可治療病人的瀕死階段。

安寧緩和醫療與安樂死最大差別在於,安樂死是刻意提早結束病人生命;自然死則未縮短病人生命,只是不作積極介入性的急救,讓末期臨終病人自然死亡。

過去「醫療法」規定:「醫院、診所遇有危急病人,應即依其設備予以救治或採取一切必要措施,不得無故拖延。」在法令規範之下,即使醫師明知病人無法存活、明知病人不希望靠維生機器痛苦地拖延生命,還是得給病人急救,否則便可能被病人家屬告過失殺人。行之有年的安寧照護,過去一直是在違法的情況中進行,即使醫院自訂「拒作心肺復甦急救同意書」讓病人簽署,仍不具法律效力。

安寧緩和醫療的適用對象是末期病人,但末期病人的界定必須由兩位醫師診斷為「不可治癒且有醫學上之證據,近期內病程進行至死亡已不可避免者」。

當然,安寧緩和醫療的先決條件是病人的意願書,病人在簽署同意書之後,可以隨時撤回。萬一病人意識昏迷、無法清楚表達意願時,也可由最親近的親屬出具同意書代替。

如果要避免因無法表達,而不能享有醫療自主權,還可以預立意願書。只要年滿二十歲具完全行為能力者,都可以預立意願書,並可預立醫療委任代理人,在自己無法表達意願時,代為簽署意願書。

美國加州早在一九七六年就已訂定「自然死法案」,許多先進國家也都有類似的法律,康泰醫療教育基金會執行長陳良娟指出,我國推動安寧療護的起步較晚,但立法在亞洲仍屬超前。

「安寧緩和醫療條例」三讀通過,第一線的醫療人員和長期推動安寧照護者,都十分欣慰。

成大醫學院護理系副教授趙可式說:「死亡可以美如秋葉,每個人都有善生善終的權利。」法案提案人之一、立委江綺雯表示,這個法案創造了四贏:病人擁有醫療自主權、家屬得以安然陪伴臨終的病人、醫界擁有高品質的照顧、政府在死亡改革上跨出了一大步。

不過,也有立法委員擔憂自然死法案可能造成預謀死亡、人命被輕易踐踏的可能性。衛生署長李明亮表示,安寧緩和醫療和傳統積極救治的觀念不同,如何避免執行偏差,侵害病人權益,衛生署將在三個月內擬定相關施行細則。

法案通過,必要配套措施也將陸續展開。健保局計畫從今年七月起,將安寧療護納入健保給付,增強醫院設立安寧病床的意願,盡快將安寧病床由目前的二百四十九床,增加到符合需求量的一千二百床。 

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尊嚴、沒有痛苦的死亡,是許多人衷心的想望,「安寧緩和醫療條例」通過後,此一願望已可達成。圖為馬偕醫院安寧病房。(薛繼光攝)

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近期文章

EN

"Natural Death" Legalized

Chang Chiung-fang /tr. by Robert Taylor

On 24 May 2000 the Palliative Care Statute received its third and final reading in the Legislative Yuan. Henceforth, it is no longer illegal to allow a person to die a "natural death." It is estimated that in Taiwan, some 10,000 patients a year will be spared the pain of futile efforts to revive them as they die, and will be able to die with dignity. "Palliative care," or "natural death," as it is often referred to, means that in accordance with a patient's expressed free will, medical staff will refrain from using cardiopulmonary resuscitation (CPR), artificial respirators, heart stimulants and other invasive medical technologies to prolong the dying process of patients with untreatable conditions.


Natural death is not the same as euthanasia. The greatest difference is that euthanasia deliberately ends a patient's life earlier than it would otherwise have ended; natural death may also "shorten" a person's life, but merely by refraining from using active, invasive resuscitation procedures, thereby allowing a terminally ill patient to die naturally.

In the past, the Medical Care Law required that: "Where a hospital or clinic encounters a patient in a dangerous condition, it shall, in accordance with its facilities, provide emergency treatment or take all such measures as are necessary, without undue delay."

The effect of this statutory requirement has been that even when doctors know that a patient will not survive, and that the patient does not wish their death to be prolonged by being painfully kept alive by machines, they still have to give the patient emergency treatment, or they may face prosecution for negligent homicide after a complaint by the patient's family. Palliative care has been practiced for many years, but in the past it was always done illegally, and even where hospitals drew up their own consent forms for patients to refuse CPR, such documents had no legal validity.

Under the new legislation, palliative treatment is only available to terminally ill patients, and for a patient to be defined as terminally ill, two physicians must diagnose that their condition is "incurable and there is medical evidence that it will inevitably progress to death within a short time."

Of course, a precondition for palliative care is a consent form signed by the patient. A patient who has signed such a consent form may retract it at any time. If a patient's consciousness is impaired and they are unable to clearly express their wishes, a consent form may be signed by close relatives instead.

To avoid people being denied the right to medical self-determination because they are unable to express their will, anyone over 20 years of age and of full capacity may make an "advance declaration" of their wishes (also known as a "living will"), and may appoint a medical representative who is empowered to sign a consent form on their behalf if they are unable to express themselves.

In 1976, the state of California enacted the Natural Death Act, America's first right-to-die statute, and many other advanced countries also have similar laws. Chen Liang-chuan, executive director of the Catholic Sanipax Medico-Social Educational Foundation, says that Taiwan has started late on the road to promoting palliative care, but the legislation is nonetheless pioneering in Asia.

The enactment of the Palliative Care Statute has been warmly welcomed by front-line medical staff, as well as by people who have long been campaigning for palliative care to be legalized.

Chao Ko-shih, an associate professor in the nursing department at National Cheng Kung University's medical school, says: "Death can be as beautiful as an autumn leaf, and every human being has a right to a good life and a good death." Legislative Yuan member Chiang Chi-wen, one of the sponsors of the legislation, says that it brings four benefits: patients gain the right to self-determination regarding their own medical care, family members can accompany dying patients in peace, the medical professions can provide the care which gives the best quality of life, and the government is taking a great step forward in reforming the way it handles citizens' death.

However, some legislators have expressed concern that the new law could be abused to deliberately cause death, and may lead to human life being too easily disrespected. Li Ming-liang, director of the Department of Health, says that the philosophy behind palliative care is different from the traditional attitude of trying to prolong life at all costs, and in drawing up the enforcement rules for the Palliative Care Statute during the next three months, the DOH will seek to prevent inappropriate implementation leading to infringement of patients' rights.

Now that the statute has been enacted, accompanying measures will also be introduced. From July of this year, the National Health Insurance Bureau plans to include palliative care in the types of care paid for by National Health Insurance, to increase hospitals' willingness to provide palliative care beds. The bureau hopes that the number of such beds can be quickly increased from the present 249 to 1,200, which would be in line with needs.

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A dignified death without pain is something many people fervently wish for. The enactment of the Palliative Care Statute should give patients greater choice in the terminal care they receive. Pictured here is the palliative care ward at Taipei's Mackay Memorial Hospital. (photo by Hsueh Chi-kuang)

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